Form 25-121 - Tax Credit Transfer Affidavit
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225-121
PROGRAM II
PRINT FORM
CLEAR FIELDS
(9-07)
TEXAS CERTIFIED INVESTOR
TAX CREDIT TRANSFER AFFIDAVIT
This form must be completed by the certified investor and each insurer to whom credits are transferred and must be filed with the Annual
Notification of Credit Transfer (Form 25-117).
Applies to Notification for Tax Year __________
• See instructions on back.
Name of Certified Investor Transferring Credits
Taxpayer Number
Address
City
State
ZIP Code
Name of Contact Person
Phone Number (Area code and number)
FAX number (Area code and number)
Email address
Name of Insurer Receiving Transfer
Taxpayer Number
Address
City
State
ZIP Code
Name of Contact Person
Phone Number (Area code and number)
FAX number (Area code and number)
Email address
PROPORTIONATE SHARE OF
TOTAL CREDITS TO BE
CREDIT AVAILABLE TO THIS
CAPCO THAT
AMOUNT OF
TRANSFERRED TO THIS INSURER
INSURER PER TAX YEAR
(Whole dollars only)
(Whole dollars only)
RECEIVED INVESTMENT
ORIGINAL INVESTMENT
$
$
$
All transfers must comply with the requirements of and are subject to the limitations in rule 34 TAC §3.830.
Once filed with the Annual Notification of Credit Transfer, this affidavit cannot be revoked for any reason.
Insurers receiving a transfer of CAPCO credits are limited to using their proportionate share of the CAPCO
credits that the original certified investor would have been entitled to use during a tax year.
This form is due no later than January 10 following the tax year that credits are transferred. Forms received
after this date will be considered as the filing for the next tax year.
For the Certified Investor:
Printed name
Daytime phone (Area code and number)
For the Transferee:
Printed name
Daytime phone (Area code and number)
You have certain rights under Chapters 552 and 559, Government Code, to review, request and correct information we have on file about you. Contact us at the
address or toll-free number listed on this form.
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